Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Camarillo Healthcare Center during CMS and state inspections, most recent first.
Surveyors found a hole in the dining corridor wall with detached siding, visible moisture inside the wall, and ants entering and exiting the opening. The damage was partially obscured by equipment, and staff were unaware of how long the issue had existed. The area was not blocked off or marked to indicate repairs were in progress.
A resident's attending physician did not consistently review or update the medication list at each required visit, resulting in progress notes that inaccurately reflected the resident's current medications. Additionally, the physician failed to write, sign, and date progress notes at each visit, and these notes were not present in the medical record until much later, leading to discrepancies in documentation timing.
A resident did not receive physician visits within the required 60-day intervals, as shown by gaps of 86 and 91 days between visits. The facility's policy and interviews with the MRS and DON confirmed that physician progress notes and timely evaluations were not completed as required.
A facility failed to assess and document pressure ulcers for a resident, including a right buttock ulcer identified but not assessed. Additional ulcers on the left buttock and sacrum were incompletely assessed. The resident refused repositioning, but no assessments were documented regarding this refusal. The facility's policies on nursing assessment and pressure ulcer management were not followed.
The facility failed to treat a resident with dignity during a room change, leaving them unable to reach their call light and personal items. Additionally, another resident was found with a strong odor and inadequate hygiene care, despite records indicating otherwise. Interviews revealed that housekeeping staff moved the resident, contrary to policy, and there was confusion about the hygiene care provided.
A facility failed to document a resident's advance directive (AD) in the re-admission agreement, despite the AD being completed and presented upon readmission. The discrepancy was confirmed through a review of the resident's electronic health record and interviews with the Director of Admission (DOA). The facility's policy states that a POLST should complement an AD, but the re-admission paperwork did not reflect the resident's AD, potentially leading to conflicts with the resident's healthcare wishes.
The facility failed to maintain a safe and homelike environment for two residents, with issues such as a broken drawer and electrical outlet cover. Additionally, the facility lacked monitoring of hot water and air conditioning temperatures, potentially affecting residents' comfort and well-being.
A resident with multiple health issues, including congestive heart failure and chronic respiratory failure, was observed eating while lying flat in bed, posing a risk of choking and aspiration. The facility failed to include interventions in the care plan to address the resident's refusal to sit upright or to educate the resident on the risks. Interviews with staff revealed a lack of documentation and physician notification regarding the resident's eating position preference.
A facility failed to monitor a resident for signs of bleeding while on the anticoagulant Eliquis. The MAR showed an order for Eliquis 2.5 mg twice daily, but there was no documentation of monitoring for bleeding. This was confirmed by the MDS coordinator. The facility's policy requires ongoing monitoring for safe medication use, which was not followed.
The facility failed to dispose of expired medications per policy, as observed during an inspection. Three expired medications, including Latanoprost, Prednisolone Acetate, and Brinzolamide, were found in a medication cart. A licensed nurse confirmed the medications were expired and needed disposal. The facility's policy requires expired medications to be removed from use.
A facility failed to follow a physician's order for a renal diet with no added salt (NAS) for a resident on dialysis. A salt packet was found on the resident's lunch tray, despite the diet order indicating a renal diet. The RD confirmed the diet should exclude added sodium, and the DSD stated the salt packet was not removed due to the meal card not specifying NAS. The resident's Order Summary confirmed the NAS diet prescription.
The facility failed to maintain sanitary conditions in its food storage and distribution areas. Debris and grime were found in the dry storage area, and ice chests used for resident ice distribution were not cleaned as per policy. These lapses had the potential to cause foodborne illness among residents.
The facility failed to follow infection control practices, including improper PPE use for a resident on EBP, unlabeled oxygen and IV tubing, and incorrect storage of respiratory equipment. Staff acknowledged these lapses, which were contrary to facility policies.
Two residents experienced unmet needs due to staff failing to follow the facility's call light policy. One resident's call light was turned off without addressing a malfunctioning bed remote, while another resident with significant medical conditions was left unattended after activating the call light for assistance. The facility's policy requires staff to address residents' needs before turning off call lights, which was not followed.
The facility failed to display 'OXYGEN IN USE' signs outside the rooms of two residents receiving oxygen therapy, as required by policy. This was confirmed through observations and interviews with staff, including a supervisor and a CNA, who acknowledged the absence of the signs and the responsibility of nurses to ensure their placement.
The facility failed to ensure proper physician justification for the use of Xanax beyond 14 days for a resident, lacking documented rationale for extending the PRN order. Additionally, informed consents for psychotherapeutic medications for another resident were missing a physician's signature, as confirmed by the DON.
A facility failed to communicate a resident's skin condition to the receiving home health agency (HHA), resulting in a delay in necessary treatment. The resident, discharged with multiple diagnoses, had pressure ulcers and moisture-associated skin damage that were not conveyed to the HHA. The Social Services Director claimed the skin assessments were faxed, but the HHA did not receive them, leading to the resident's caretakers being unaware of the condition until the HHA's assessment.
A facility failed to communicate necessary discharge information to a resident, their representative, and the home health agency. The resident, with multiple health issues, was discharged without receiving required instructions due to the representative leaving before signing paperwork. Additionally, the home health agency did not receive complete information about the resident's skin conditions, impacting ongoing care.
A facility's policy allowed late entries without a time limit, leading to a twelve-day delay in discharge planning notes for a resident. The DON acknowledged the resident left without signing discharge paperwork, and the SSD confirmed all notes were late entries. The policy was not reviewed by the governing body, and the practice was inconsistent with Medicare's expectations for timely documentation.
A facility failed to maintain a complete medical record for a resident when discharge planning notes were missing. The resident, discharged with home health services, left without signing discharge paperwork. The Social Services Director acknowledged that notes were entered as late entries six days post-discharge, just before a meeting with a Health Facility Evaluator Nurse. The facility's policy allowed for late entries without a specific time limit, conflicting with accepted standards requiring timely documentation.
A facility failed to accurately document fluid intake for two residents, leading to potential dehydration and hospital admissions. One resident was sent to the ER for shortness of breath and diagnosed with sepsis and pneumonia, while another was admitted with altered mental status, pneumonia, UTI, and sepsis. Discrepancies were found between daily intake totals and 24-hour records, and IV fluids were not included in the intake totals.
A resident with a urinary tract infection and chronic kidney disease was not properly communicated to their family representative about a change in condition. Despite being observed lethargic and having a urinalysis indicating infection, there was no documentation of notification to the responsible party. The resident was later transferred to the hospital due to altered mental status, contrary to the facility's policy requiring communication of such changes.
A facility failed to document a resident's intake and output as specified in the care plan, which was crucial due to the resident's risk for weight loss, malnutrition, dehydration, and fluid imbalance following surgery. The care plan required detailed monitoring and documentation of fluid intake and output, but records showed these were not closely monitored, leading to an inability to assess if hydration needs were met. The resident experienced a 5% weight loss shortly after admission, and the DON confirmed the missing documentation.
Damaged Corridor Wall with Moisture and Insect Infestation
Penalty
Summary
A deficiency was identified when surveyors observed a hole in the wall of the dining corridor leading from the dining room to the medical records office. The bottom wall siding was detached, creating an opening at the base of the wall, and several ants were seen entering and exiting through this opening. The wall damage was partially hidden by a lift device, and the charge nurse present during the observation confirmed the damage but was unaware of how long it had existed. Further inspection with the facilities director revealed that the inside of the wall was wet, and this was confirmed by touch. The facilities director could not explain the source of the moisture. The director of nursing was informed of the wet wall and the presence of ants, acknowledging the damage and the open area. The damaged area was not blocked off or marked with caution tape or signage to indicate ongoing repairs.
Failure to Ensure Timely and Accurate Physician Documentation and Medication Review
Penalty
Summary
The facility failed to ensure that the attending physician for a sampled resident conducted a review of the resident's medications at each required visit. Review of the facility's policy indicated that the physician should review the resident's total program of care, including medications, at each visit. However, examination of the resident's medical record revealed that the physician's progress notes consistently listed the same medications across multiple visits, despite documented changes in the resident's medication regimen throughout the year. Nursing progress notes and interdisciplinary team documentation showed that new medications and dosage changes were ordered at various times, but these updates were not reflected in the physician's progress notes. Additionally, the facility did not ensure that the physician wrote, signed, and dated a progress note at each required visit, nor that these notes were present in the resident's medical record. The medical records supervisor confirmed that there were no physician progress notes for the resident in either the hard copy or electronic medical record for the year in question until the physician was contacted and asked to provide them. The physician acknowledged that he had not sent any visit progress notes to the facility and that his notes were stored in his office system, which the facility did not have access to. Upon receiving the physician's notes, it was found that all notes for the year were created, documented, reviewed, and signed on the same day, well after the actual visit dates. This resulted in discrepancies regarding when the notes were performed and documented, and the progress notes did not accurately reflect the resident's current medication regimen at the time of each visit.
Failure to Ensure Timely Physician Visits and Documentation
Penalty
Summary
The facility failed to ensure that a resident received timely physician visits as required. Upon review of the resident's medical record, it was found that the physician's visit notes for the year were missing from the record until the medical records supervisor (MRS) contacted the physician to obtain them. The notes provided showed that the intervals between some physician visits exceeded the required 60-day timeframe, with gaps of 86 and 91 days between visits. The facility's policy requires physician progress notes to be written at each visit, at least every 30 days for the first 90 days after admission and at least once every 60 days thereafter. The deficiency was confirmed through interviews with the MRS and the director of nursing (DON), who acknowledged that the resident was not seen by the physician within the required intervals. The lack of timely physician evaluations was identified through a review of the visit notes and facility policy, and the DON confirmed that residents are to be seen at least once every 60 days with documentation at each visit.
Failure to Assess and Document Pressure Ulcers
Penalty
Summary
The facility failed to ensure proper assessment and documentation of pressure ulcers for a resident, identified as Resident 2. A pressure ulcer on the right buttock was identified on 8/10/24, but no assessment was conducted or documented. During a review of the resident's medical records, it was confirmed by the assistant director of nursing and the treatment nurse that the initial assessment was not performed as required. Additionally, assessments for other pressure ulcers on the left buttock and sacrum were incomplete, lacking necessary details such as staging, measurements, and condition of the surrounding tissue. Furthermore, Resident 2 had refused to be turned and repositioned, as noted in the progress notes from 7/21/24 to 8/19/24. Despite this refusal, there were no documented assessments regarding the resident's refusal to turn and reposition. The director of nursing acknowledged the lack of documentation and did not provide an explanation for the missing assessments. The facility's policies on nursing assessment and pressure ulcer management were not adhered to, as ongoing assessments and documentation were not conducted as required.
Failure to Ensure Resident Dignity and Hygiene
Penalty
Summary
The facility failed to ensure that Resident 624 was treated with dignity and respect during and after a room change. During an observation, it was noted that Resident 624's call light and personal belongings were out of reach, leaving the resident unable to call for help if needed. The family member of Resident 624 was visibly upset and expressed concern about the resident's inability to communicate or access personal items. Interviews with the Housekeeping Supervisor and Director of Staff Development confirmed that housekeeping staff, rather than nursing staff, moved Resident 624, which was not in accordance with the facility's policy. The Director of Nursing also confirmed that moving residents was a nursing task, not a housekeeping duty. The facility also failed to ensure that Resident 31 was free of foul body odor, which could violate the resident's rights to quality care. During an observation, Resident 31 was found in bed with a stained hospital gown and sheets, tangled hair, and a strong, unpleasant odor. The resident stated a preference for bed baths but had not received one in several days. The facility's records indicated that Resident 31 received a sponge bath, but this was not observed during the inspection. Interviews with a CNA and the shower technician revealed a lack of clarity about when Resident 31 last received proper hygiene care, highlighting a failure in the facility's care practices.
Failure to Document Advance Directive in Re-admission Agreement
Penalty
Summary
The facility failed to ensure that an advance directive (AD) was noted in the re-admission agreement for a resident, which could potentially lead to the facility not honoring the resident's medical decisions regarding end-of-life treatment. The resident was readmitted to the facility, and although the AD was completed and signed prior to readmission, the re-admission agreement incorrectly indicated that the resident did not have an AD. This discrepancy was confirmed during a review of the resident's electronic health record and through interviews with the Director of Admission (DOA). The DOA acknowledged that the re-admission paperwork should have reflected the existence of the AD, which was presented to the facility upon the resident's readmission. The facility's policy and procedure on Physician Orders for Life-Sustaining Treatment (POLST) states that the POLST form should complement a resident's AD, but it does not replace it. The failure to accurately document the resident's AD in the re-admission agreement could lead to conflicts with the resident's healthcare wishes.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by issues in two resident rooms. During an observation and interview with the Housekeeping Supervisor, it was noted that a closet drawer in one resident's room could not be opened because it was off its track, and an electrical outlet cover was broken above another resident's bed. The Housekeeping Supervisor confirmed these issues and acknowledged the need for repairs. The facility's policy on maintaining a safe and homelike environment was reviewed, which indicated that housekeeping and maintenance services should be provided as necessary to ensure a sanitary, orderly, and comfortable environment. Additionally, the facility did not have monitoring logbooks for hot water temperature and air conditioning thermostat levels, as confirmed by the Maintenance Supervisor and Administrator. The facility's policies and procedures outlined specific standards for water and air temperatures in resident areas, but there was no evidence of regular monitoring or adjustments being made. This lack of monitoring had the potential to affect the residents' comfort and well-being, as the facility failed to ensure that environmental conditions met the established standards.
Failure to Address Resident's Refusal to Sit Upright While Eating
Penalty
Summary
The facility failed to ensure a comprehensive care plan for a resident who refused to sit upright while eating, which posed a risk of choking and aspiration. The resident, who had multiple diagnoses including congestive heart failure, chronic respiratory failure, gastro-esophageal reflux disease, and a cognitive communication deficit, was observed eating while lying flat in bed. Despite the resident's preference to eat lying down due to pain and difficulty breathing when sitting up, the care plan did not include interventions to address this refusal or educate the resident on the associated risks. Interviews with facility staff, including a nurse supervisor, certified nurse assistant, licensed nurse, and the Director of Nursing, revealed that there were no documented interventions or physician notifications regarding the resident's refusal to eat upright. Additionally, there was no documentation in the medical record indicating that the risks of eating while lying down were explained to the resident or their representative. The facility's policy required the interdisciplinary team to develop a comprehensive care plan based on the resident's needs, which was not adhered to in this case.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure proper monitoring for signs and symptoms of bleeding for a resident who was prescribed the anticoagulant Eliquis. During an observation and record review, it was found that the medication administration record (MAR) for January 2025 indicated an order for Eliquis 2.5 mg to be taken twice daily. However, there was no documentation of monitoring for bleeding in the MAR. This was confirmed by the Minimum Data Set (MDS) coordinator, who verified the absence of monitoring for bleeding side effects in the resident's chart. The facility's policy and procedure on Medication Management, dated May 2022, requires ongoing monitoring for safe medication use, which was not adhered to in this case.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to dispose of expired medications according to its policy and procedure, which had the potential for expired medications to be administered to residents. During an observation and interview with a licensed nurse, three expired medications were found in medication cart two. These included one vial of Latanoprost 0.005% solution, one vial of Prednisolone Acetate 1%, and one vial of Brinzolamide 1%, all of which had an expiration date of 2/4/25. The licensed nurse acknowledged that the medications were expired and needed to be placed in the waste container in the medication room. The facility's policy on the storage of medications indicated that expired medications should be removed from use for appropriate disposal.
Failure to Follow Renal Diet Order
Penalty
Summary
The facility failed to adhere to a physician's order for a renal diet with no added salt (NAS) for a resident undergoing dialysis treatment. During an observation, a salt packet was found on the lunch tray of the resident, despite the diet order indicating a renal diet. The Registered Dietician confirmed that the resident's diet should not include added sodium. The Director of Staff Development, responsible for verifying meal trays, stated that the salt packet was not removed because the meal card did not specify NAS. A review of the resident's Order Summary confirmed the prescription of a renal NAS diet by the physician. The facility's policy on Liberal Renal Diets suggests consulting a licensed and registered dietician for individualized assessments, acknowledging that nutritional needs can vary among kidney patients.
Failure to Maintain Sanitary Conditions in Food Storage and Distribution
Penalty
Summary
The facility failed to adhere to its cleaning policy and procedures, resulting in unsanitary conditions in the food storage and distribution areas. During an observation, extensive debris and grime were found in and around the floor drain in the dry storage area. Additionally, produce, food scraps, and trash debris were observed behind and under metal racks in the walk-in refrigerator and behind the ice machine. The Registered Dietician and the Dietary Assistant Manager acknowledged that the drain was dirty and the floor appeared unswept and unmopped, contrary to the facility's policy that requires floors to be mopped at least once per day. Furthermore, the facility did not follow its policy for cleaning ice chests used to distribute ice to residents. The Ice Container Daily Cleaning Log for February 2025 showed that the ice chests were not cleaned on two specific days. The Dietary Assistant Manager confirmed the log was incomplete, indicating a failure to clean and sanitize the ice chests before and after each use, as required by the facility's policy. These lapses in cleaning procedures had the potential to cause foodborne illness among the highly susceptible resident population.
Infection Control Deficiencies in PPE Use and Equipment Storage
Penalty
Summary
The facility failed to ensure proper infection control practices were followed for a resident on Enhanced Barrier Precaution (EBP). During an observation, an occupational therapist (OT) was seen assisting a resident without wearing a gown, which is required PPE for residents on EBP. The OT acknowledged the mistake and confirmed that the resident was on EBP due to an indwelling urinary catheter. Additionally, the OT improperly removed the gown outside the resident's room, contrary to the facility's policy that requires PPE to be discarded before exiting the room. Another deficiency was observed with a resident's oxygen and intravenous (IV) tubing. The oxygen tubing was not labeled, and the IV tubing lacked a date and nurse's initials, which are required by the facility's policy. A certified nurse assistant confirmed the absence of labeling, and the assistant director of nursing acknowledged the need for proper labeling per policy. Furthermore, respiratory care equipment for another resident was not stored correctly, risking cross-contamination. A nasal cannula and nebulizer mask were left exposed and not covered, contrary to the facility's practice of storing such equipment in plastic bags when not in use. Both a licensed nurse and the infection preventionist confirmed the improper storage, and the facility could not provide a policy addressing the proper storage of these items.
Failure to Respond to Call Lights as per Policy
Penalty
Summary
The facility failed to adhere to its call light policy and procedure, resulting in unmet needs for two residents. In the first instance, an unidentified staff member turned off the call light for a resident without addressing the resident's concern about a malfunctioning bed remote control. The resident had to activate the call light a second time for the same issue. The Infection Preventionist confirmed that the facility's policy requires call lights to remain on until the resident's issue is resolved, which was not followed in this case. In the second instance, a resident with significant medical conditions, including hemiplegia and encephalopathy, activated the call light for assistance with a soiled brief and getting out of bed. The Director of Staff Development entered the room, turned off the call light, and left without addressing the resident's needs or even acknowledging the resident's presence. The Director later admitted to not realizing the resident was in the room. The facility's policy mandates that staff must check in with residents and address their needs before turning off the call light, which was not adhered to in this situation.
Failure to Display Oxygen Use Signs
Penalty
Summary
The facility failed to ensure the safety of residents, staff, and visitors by not placing 'OXYGEN IN USE' signs outside the rooms of two residents who were receiving oxygen therapy. This deficiency was identified during observations and interviews conducted by surveyors. In one instance, the Housekeeping/Maintenance/Central Supply Supervisor confirmed that there was no sign outside the room of a resident on oxygen, despite acknowledging that it was the nurses' responsibility to ensure the sign was in place. Similarly, a Certified Nurse Assistant confirmed the absence of a required sign outside another resident's room who was also on oxygen. The facility's policy, dated November 2024, mandates the use of 'NO SMOKING/OXYGEN IN USE' signs to indicate when oxygen therapy is being administered, but this policy was not followed in these cases.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure proper physician justification for the use of the antianxiety medication Xanax beyond 14 days for a resident. The medication administration record indicated an order for Xanax 0.25 mg as needed for anxiety, which started on December 17, 2024, with a duration of 90 days. However, there was no documented rationale from the attending physician or prescribing practitioner to extend the PRN order beyond the 14-day limit as required by the Code of Federal Regulations. During the exit conference, the facility was unable to provide the appropriate policy on the use of as-needed psychotropic medication. Additionally, the facility did not obtain a physician's signature on informed consents for psychotherapeutic medications for another resident. The review of the facility's policy indicated that informed consent should be obtained by the prescriber when drugs are used to control behavior or treat a disordered thought process. However, the Facility Verification of Resident Informed Consent Psychotherapeutic Medications for several dates lacked a physician's signature. The Director of Nursing confirmed that the consents were missing the required physician signature.
Failure to Communicate Resident's Skin Condition to HHA
Penalty
Summary
The facility failed to ensure that appropriate and necessary information was communicated to the receiving home health agency (HHA) for a safe and effective transition of care for a resident. The resident, who was discharged to home with HHA services, had multiple diagnoses including pneumonia, acute respiratory failure, and mild cognitive impairment. Upon discharge, the resident's caretakers were not informed of the resident's pressure ulcers and moisture-associated skin damage (MASD) in various areas, including the groin, scrotal, and perirectal regions. This lack of communication resulted in a delay in necessary skin treatment until the HHA conducted an assessment and discovered a stage 2 pressure ulcer on the sacrum. The Social Services Director (SSD) stated that documents, including skin assessments, were faxed to the HHA, but the HHA Director of Patient Care Services reported not receiving any skin assessments or wound care orders. The order summary report faxed to the HHA did not include wound care instructions. The SSD later mentioned that the skin assessments were faxed separately but could not confirm their receipt. The HHA Chief Operating Officer confirmed that no separate fax or email regarding the skin assessments was received. This communication failure led to the resident's responsible party being unaware of the skin condition, delaying treatment.
Failure to Communicate Discharge Information
Penalty
Summary
The facility failed to communicate necessary discharge information to a resident, the resident's representative, and the continuing care provider at the time of an anticipated discharge. The resident, who had multiple diagnoses including pneumonia, acute respiratory failure, and mild cognitive impairment, was discharged to home without receiving the required discharge instructions. The resident's daughter, who was present during the discharge, did not sign the discharge paperwork and left the facility with the resident before the discharge information could be communicated. Additionally, the facility did not provide the home health agency with complete information regarding the resident's skin conditions, including pressure ulcers and other skin issues that required monitoring and treatment. The Order Summary Report sent to the home health agency lacked details about the resident's skin care needs, which were critical for ongoing care. This omission was confirmed by the Director of Patient Services, who noted that the home health agency did not receive information about the resident's pressure ulcers, resulting in a lack of appropriate care instructions for the resident's condition.
Deficiency in Timely Documentation of Late Entries
Penalty
Summary
The facility failed to ensure that its Late Entry documentation policy and procedure met professional standards for timely documentation. The policy in question stated that there was no time limit for writing a late entry, which led to a twelve-day delay in the availability of discharge planning notes in the medical record of a resident. This delay was identified during an interview with the Director of Nursing (DON), who acknowledged that the resident did not receive discharge information and left the facility without signing the necessary paperwork. The Social Services Director (SSD) later provided social services notes, which were all entered as late entries on the day of the interview, despite the conversations having occurred over a ten-day period earlier in the month. The facility's policy allowed staff to make late entries without a specific timeframe, which was confirmed by the SSD. The policy was not documented as having been reviewed by the governing body, and the DON could not provide documentation on when the policy was implemented or revised. The facility's practice of allowing late entries without a time limit was inconsistent with Medicare's expectations for timely documentation, which generally allows for delayed entries within a reasonable timeframe of 24 to 48 hours. This deficiency in documentation practices has the potential to compromise the timely continuity of care for residents.
Incomplete Medical Record Due to Missing Discharge Planning Notes
Penalty
Summary
The facility failed to maintain a complete medical record for a resident, as required by professional standards, when discharge planning notes were missing from the resident's medical record. The resident, who had been admitted with multiple diagnoses including pneumonia, acute respiratory failure with hypoxia, and mild cognitive impairment, was discharged to home with home health services. However, the discharge process was not properly documented, leading to a lack of discharge planning notes in the resident's medical record. During an interview, the Director of Nursing (DON) revealed that the resident left with family without signing the discharge paperwork. The Social Services Director (SSD) later acknowledged that all social services notes were entered as late entries, six days after the resident's discharge, and just before a meeting with a Health Facility Evaluator Nurse (HFEN). The facility's policy allowed for late entries without a specific time limit, but this practice did not align with accepted standards that require timely documentation. This failure had the potential to cause miscommunication and confusion among the healthcare team, affecting the resident's continuity of care.
Inaccurate Fluid Intake Documentation Leads to Hospital Admissions
Penalty
Summary
The facility failed to accurately document fluid intake for two residents, which potentially affected their hydration status and contributed to their hospital admissions. For the first resident, physician orders required recording fluid intake each shift and calculating the 24-hour intake on the night shift. However, discrepancies were found between the daily intake totals and the 24-hour intake records, which did not match as they should have. This resident was later sent to the emergency room for shortness of breath and diagnosed with sepsis and pneumonia. The second resident also had physician orders to record fluid intake each shift due to poor appetite, with an estimated fluid need of not less than 1500 cc/day. The intake records showed significant discrepancies, with daily totals not matching the 24-hour intake records and consistently falling below the recommended fluid intake. The resident had an IV infusion on specific dates, but the nursing staff failed to include these in the intake totals. This resident was admitted to the hospital with altered mental status, pneumonia, urinary tract infection, and sepsis. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the inaccuracies in the intake records for both residents. The facility's policy required intake and output to be recorded by each shift, but the records did not reflect this accurately. The ADON acknowledged that the intake totals were not accurate and that the physician was not informed of the resident's failure to meet the recommended fluid intake. Lab results for the second resident showed elevated blood urea nitrogen and creatinine levels, indicating potential dehydration.
Failure to Notify Family of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the family representative of a change in condition for a resident who was readmitted with a urinary tract infection and chronic kidney disease. On May 6, the resident was observed to be sluggish and lethargic, prompting a physician to order a urinalysis. The test results on May 8 indicated blood in the urine, suggesting an infection, but there was no documentation of notification to the responsible party in the resident's medical record. On May 11, the resident was again found lethargic and was transferred to the hospital due to altered mental status. The facility's policy requires that routine changes, including abnormal laboratory results, be communicated to the physician and responsible party, with all attempts documented in the nursing progress notes.
Failure to Document Resident's Intake and Output
Penalty
Summary
The facility failed to ensure proper documentation of intake and output for a resident, which was specified in the care plan. The resident was at risk for weight loss, malnutrition, dehydration, and fluid and electrolyte imbalance due to recent surgery. The care plan required monitoring of intake and output every shift, recording total daily intake and output, and documenting the quality, color, odor, and consistency of urine, as well as the patient's hydration status. Additionally, any discrepancies in fluid intake or balance were to be reported to the physician every shift. A review of the resident's intake and output record revealed that these were not closely monitored, making it impossible to determine if the resident met her daily hydration requirements. The resident's weight summary indicated a 5% weight loss within 15 days of admission to the facility. During an interview, the DON confirmed the missing intake and output documentation for the resident.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near Camarillo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. John's Hospital Camarillo D/p Snf | 2.5 mi | ★★★★★ | 0 | 0 |
| Alta Healthcare Center Of Camarillo | 3.5 mi | ★★★★★ | 1 | 0 |
| Mary Health Of The Sick Convalescent & Nursing Hos | 6.8 mi | ★★★★★ | 0 | 0 |
| Glenwood Care Center | 7.4 mi | ★★★★★ | 1 | 0 |
| Maywood Acres Healthcare | 7.9 mi | ★★★★★ | 18 | 0 |
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